Online Accommodation Form

Part I - Request for Accommodation Letters

* Your Name:

* Date:

* Original Request or Schedule Change:

* Zip Card ID#/ EMPL ID (This can be found on the back of your Zip Card, under the bar code. Type the numbers located after the initial zeros.):

* Current Address (Street/ Box, City, State, and Zip code):

* Current Phone Number:

* Current Cell Phone Number:

* Semester:

* How many letters do you need? (In how many classes are you using accommodations?):

If you are a student at the Medina County University Center (MCUC), please check this box: MCUC student

If you are taking INTERMEDIATE ALGEBRA this semester please check the following box and read the link on INTERMEDIATE ALGEBRA

Intermediate Algebra

If you like, use the following buttons to jump ahead in the form (Recommended for people using only one of the following areas for accommodations):

Part 2 - Alternative Media
Part 3 - Auxiliary Aids and Services
Part 4 - Adaptive Technology
Part 5 - Classroom Accessibility and Seating Accommodations
Part 6 - Adaptive Study Strategies Program (ASSP)
Part 7 - Send form to request letters

Part 2 - Alternative Media

If you use alternative textbooks or media, which types do you use. In order to pick up your alternative media you are required to bring a copy of your receipt or other proof of purchase.
Text files on CD for use with screen reader
Book files to use with Kurzweil 3000
Large Print or Tiff files
Braille

in which classes do you need Alternative Textbooks (Please state with as much detail as possible, such as "English Composition 3300:111-000."):

Part 3 - Auxiliary Aids and Services

Which Auxiliary Aids and Services do you use
Notetakers
Sign Language Interpreter
CART (Computer Aided Real Time Captioning)

Please indicate which classes do you need Auxiliary Aids and Services (Please state with as much detail as possible, such as "English Composition 3300:111-000."):

Part 4 - Adaptive Technology:

Hardware and Equipment

What equipment do you need to check out? We have a limited number of each item, however, if they are out of stock your name will be put on a list and we will call you as soon as an item is available.

Assistive Listening Devices (ALDs)
AlphaSmart
Daisy Player for RFBD and CSC tapes
Tape Recorder for Classroom use
Calculator for Classroom use

Part 5 - Classroom Accessibility and Seating Accommodations:

Check if they apply to your accommodations
Classroom Relocation
Seating / Table Accommodations
Walk through with a disability specialist
Lock-in Classes: Ensures that current classroom location will not change.

Please indicate which classes do you need Accessibility and Seating Accommodations (Please state with as much detail as possible, such as "English Composition 3300:111-000 - adjustable table"):

Part 6 - Adaptive Study Strategies Program (ASSP)

I would like to participate (Make an appointment with your Disability Specialist) Adaptive Study Strategies Program

Read the following agreements and if they pertain to you, you must check them for your accommodations to process.

Read and check box verifying your agreement:
* "I understand that I need to pick up my accommodation letters from the Office of Accessibility and deliver them to each of my instructors by the end of the second week of the semesters in a 15-week session or its equivalent time frame for shorter sessions."

I would like my accommodation letter in alternative format:
Large Print
Disk
Braille

Comments

*Enter Your Full E-Mail Address in order for Accommodation form to Process: If you do not get an e-mail reply in one week, your accommodation letters did not process and you MUST come to the office to finalize them.

*Please enter your e-mail address once more to help insure your identity.

By pressing submit you are agreeing that the above information is correct and that if any changes regarding this information occur (e.g., a change of classes) it is your responsibility to contact the Office of Accessibility or resubmit this form with the necessary changes.

Office of Accessibility Online Accommodation and Service Request Form

Intermediate Algebra Information

Headings which are marked by a "*" MUST be filled out for us to process your request. All Accommodations must be pre-approved by a Disability Specialist before your request!